additional stability of the IOL in preparation for graft insertion, a miotic agent such

as carbachol 0.01 % is injected intracamerally to constrict the pupil. This manoeuvre

also serves to prevent iris prolapse and inadvertent insertion of the graft into the posterior chamber. We routinely perform an inferior peripheral iridectomy in all cases to

avoid the risk of pupil block (Fig. 1.6). Lastly, all wounds are sutured to ensure air

and water tightness, to avoid problems of air leakage and hypotony (Fig. 1.7).

1.4

Outcomes

Current literature on the outcomes of combined endothelial keratoplasty and cataract surgery is promising but limited. Covert et al. [7], in prospective noncomparative case series of 21 eyes of 21 consecutive patients with Fuchs endothelial

a

b

Fig. 1.5 (a) The capsulorrhexis is undersized to prevent IOL prolapse out of the capsular bag.

2.4 Performing the Endothelial Keratoplasty After an IOL Exchange or Repositioning

References

2.1

15

16

16

22

22

22

26

32

33

36

Introduction

Endothelial keratoplasty (EK) has surpassed penetrating keratoplasty (PK) as the surgical standard of care for patients with endothelial failure. Worldwide, the most common indication for EK is Fuchs endothelial dystrophy (FED). The second most

common is “post-cataract edema,” often referred to as pseudophakic bullous keratopathy (PBK), which accounts for over 8,000 transplants performed for endothelial

failure a year in the United States [1]. While classically the term PBK indicates

Electronic supplementary material: The online version of this chapter (doi:10.1007/978-81322-2821-9_2) contains supplementary material, which is available to authorized users.

damage of the endothelium as a direct result of a poorly positioned or dislocated intraocular lens (IOL), the term is now often used in any pseudophakic patient with corneal decompensation. Regardless of the terminology, the corneal surgeon is likely to

encounter patients with dislocated lenses who also require corneal transplantation.

There are now numerous published articles discussing the challenges and complications, as well as the good outcomes, that can be achieved when EK is performed in complex situations such as corneal failure in eyes with anterior chamber

lenses, with anterior chamber vitreous present, after previous PK, and in eyes with

previous trabeculectomies and glaucoma drainage devices (GDD) [2–15]. There are

also a few studies that have addressed the potentially good outcomes that can be

achieved with the secondary placement of IOLs, either with lens exchange or in the

chamber lenses will lead to endothelial trauma and eventually endothelial failure

[17–19]. While the temptation may be to immediately implicate any anterior chamber lens as the cause of corneal failure, this is not always the case. Well-fitting anterior chamber lenses may not be damaging to the endothelium [20]. It is important to

realize that most commonly an anterior chamber lens is placed as a result of a “traumatic” situation, such as after a true trauma to an eye requiring surgery, as a result

of a “traumatic” cataract surgery or possibly after multiple previous surgeries, which

resulted in a lack of proper capsular support. It may be the previous intraocular

manipulations that led to endothelial damage and subsequent corneal failure. Some

clues to the etiology of endothelial failure lie in the history alone. A patient who has

had successful vision rehabilitation with the presence of a stable anterior chamber

lens for many years may simply require replacement of the endothelium leaving the

anterior chamber lens in place. Multiple studies have demonstrated the success of

such surgery by means of deep lamellar endothelial keratoplasty (DLEK),